ORTHOEADIC HISTORY

TAKING
 History taking skills
• History taking is the most important step in
making a diagnosis .
• A clinician is 60 %closer to making a diagnosis
with a thorough history; remaining 40 %is
a combination of examination findings
and investigations .
• History taking can either be of a traumatic or
non-traumatic injury.
 Objective
• At the end of this session, students should be
able and know how to take a MSK relevant
history.
 Competency expected from the
students
• Take a relevant history, with the knowledge of
the characteristics of the major
musculoskeletal conditions
 STRUCTURE OF HISTORY
• Demographic features • Drug Hx
• Chief complaint • Occupational Hx
• History of presenting • Allergy
illness • Family Hx
– MOI • Social Hx
– Functional level
• MSK systemic review
• Systemic enquiry
• PMH
• PSH
 MSK systemic review
• Pain
• Stiffness
• Swelling
• Instability
• Deformity
• Limp
• Altered Sensation
• Loss of function
• Weakness
 Pain
• Location
– Point to where it is
• Radiation
– Does the pain go anywhere else
• Type
– Burning, sharp, dull
• How long have you had the pain
• How did it start
– Injury
• Mechanism of injury
• How was it treated?
– Insidious
 Pain
• Progression
– Is it getting worse or is it remaining stable
– Is it better, worse or the same
• When
– Mechanical / Walking
– Rest
– Night
– Constant
• Aggravating & Relieving Factors
– Stairs
– Start up, mechanical
– Pain with twisting & turning
– Up & down hills
– Kneeling
– Squatting
 Pain
• Where: location/radiation
• When: onset/duration WWQQAA
• Quality: what it feels like
• Quantity: intensity, degree of disability
• Aggravating and Alleviating factors
• Associated symptoms
 Swelling
• Duration
• Local vs generalised
• Onset
• Constant or comes and goes
• Progression: same size or↑
• Aggravated and relived factors
• Associated with injury or reactive
• Soft tissue, joint, bone
• Rapidly or slowly
• Painful or not
 Instability
• Onset
• How dose it start?
• Any Hx of trauma?
• Frequency
• Trigger/aggravated factors
• True = Giving way
• Buckling 2dary to pain
• I can not trust my leg!
• Associated symptoms
– Swelling
– Pain
 Deformity
• When did you notice it?
• Progressive or not?
• Associated with symptoms
like pain or stiffness
• Impaired function or not?
• Past Hx of trauma or surgery
• PMHx (neuromuscular,
polio…etc)
 Limping
• Painful vs painless
• Onset (acute or chronic)
• Progressive or not?
• Use walking aid?
• Functional disability?
• Traumatic or non traumatic?
• Associated with swelling, deformity, or fever.
 Loss of function
• How has this affected your life
• Home (Activities of Daily Living [ADL])
– Praying
– Using toilet
– getting out of chairs / bed
– socks
– stairs
– squat or kneel for gardening
– walking distance
– get in & out of cars
• Work
• Sport
– Type & intensity
– Run, jump
 Mechanical symptoms
Locking / clicking Giving way
• Loose body, meniscal • Buckling 2° pain
tear • ACL
• Patella
 Red flags
• Weight loss
• Fever
• Loss of sensation
• Loss of motor function
• Sudden difficulties with urination or
defecation
 Risk factors
• Age • Occupation and Sport
• Gender • Family History (SCA)
• Obesity • Infections
• Lack of physical activity • Medication (steroid)
• Inadequate dietary • Alcohol
calcium and vitamin D • PHx MSK
• Smoking injury/condition
• PHx Carcinoma
 Current and previous history of
treatment
• Nonoperative
– Medications
• Analgesia
• How much
• How long
– Physiotherapy
– Orthotics
• Walking sticks
• Splints
• Operative
– What, where and when?
– Perioperative complications
Pain
• Location
Knee
• point to where it is radiation
• does the pain go anywhere else
• Progression
• Type
• Burning, sharp, dull
• Is it getting worse or is it remaining stable
• How long have you had the pain • Is it better, worse or the same
• How did it start • When
• Injury – Mechanical / Walking
• Mechanism of injury – Rest
• Position of leg at time of injury – constant
• Direct / indirect • Aggravating & Relieving Factors
• Audible POP – stairs
• Could you play on or did you – start up, mechanical
leave the field?
– pain with twisting & turning
• ACL
• Did it swell at the time
– up & down hills
• Immediately – kneeling
• Haemathrosis – squatting
• Delayed
• Traumatic synovitis
• Audible POP
• How was it treated?
• Insidious
 Spine
• Pain
– radiation exact location
• L4
• L5
• S1
– Aggrevating,relieving Hills
• Neuropathic
» - extension & walking downhill
» ¯ walking uphill & sitting
• vascular
» - walking uphill
• generates more work
» ¯ rest
• standing is better than sitting due to pressure gradient
– stairs
– shopping trolleys
– -coughing, straining
– sitting
– forward flexion
 Spine
• Associated symptoms • Red Flags
– Paresthesia – Loss of weight
– Numbness – Constitutional symptoms
– Weakness – Fevers, sweats
• L4 – Night pain, rest pain
• L5 – History of trauma
• S1
– immunosuppresion
– Bowel, Bladder
– Cervical myelopathy
• Clumbsiness of hand
• Unsteadiness
• Manual dexterity
 Shoulder
• Age of the patient
– Younger patients - shoulder instability and
acromioclavicular joint injuries are more prevalent
– Older patients - rotator cuff injuries and degenerative joint
problems are more common
• Mechanism of injury
– Abduction and external rotation - dislocation of the
shoulder
– Direct fall onto the shoulder - acromioclavicular joint
injuries
– Chronic pain upon overhead activity or at night time -
rotator cuff problem.
 Shoulder
• Pain • Aggravating / Relieving
– Where factors
• Rotator Cuff – Position that ↑
–anterolateral & symptoms
superior • RC: Window
–deltoid cleaning position
insertion • Instability: when
• Bicipital tendonitis arm is overhead
–Referred to – Neck pain
elbow • Is shoulder pain
related to neck
pain
• ask about
radiculopathy
 Shoulder
• Causes
– AC joint
– Cervical Spine
– Glenohumeral joint & rotator cuff
• Front & outer aspect of joint
• Radiates to middle of arm
– Rotator cuff impingement
• Positional : appears in the window cleaning position
– Instability
• Comes on suddenly when the arm is held high
overhead
– Referred pain
• Mediastinal disorders, cardiac ischaemia
 Shoulder
• Associated
– Stiffness • Loss of function
– Instability / Gives way – Home
• Severe – feeling of joint • Dressing
dislocating – Coat
• Usually more subtle – Bra
presenting with • Grooming
clicks/jerks
• What position – Toilet
• Initial trauma – Brushing hair
• How often • Lift objects
• Ligamentous laxity • Difficulty working with
arm above shoulder
– Clicking, Catching / grinding height
• If so, what position – Top shelves
– Weakness – Hanging washing
• Rotator cuff – Work
– especially if large tear – Sport
– Pins & needles, numbness